What physical examination findings are most likely in a 45-year-old man with complaints of exhaustion, difficulty concentrating, loud snoring, and nocturnal thrashing, who smokes two packs of cigarettes daily and has a history of not being examined by a healthcare provider in over 20 years?

From the Guidelines

The physical examination of this 45-year-old man is most likely to reveal signs of obstructive sleep apnea (OSA) and chronic obstructive pulmonary disease (COPD), including a low-lying soft palate, scattered wheezes, and possible hyperinflation of the chest. The patient's symptoms of exhaustion, difficulty concentrating, loud snoring, and nocturnal thrashing, combined with his history of heavy smoking, suggest a high risk for both OSA and COPD 1. A comprehensive sleep evaluation and physical examination, as recommended by the American Academy of Sleep Medicine, should include a thorough sleep history and examination of the respiratory, cardiovascular, and neurologic systems 1. The examiner should pay particular attention to observations regarding snoring, witnessed apneas, nocturnal choking or gasping, restlessness, and excessive sleepiness.

Key findings on physical examination may include:

• A low-lying soft palate, which can contribute to upper airway obstruction during sleep
• Scattered wheezes throughout all lung fields, indicating airway obstruction consistent with COPD
• Possible hyperinflation of the chest, suggesting COPD
• Signs of respiratory and cardiovascular strain, such as hypertension and elevated jugular venous pressure

Given the patient's significant smoking history and symptoms, urgent smoking cessation counseling, pulmonary function testing to confirm COPD, and a sleep study to diagnose OSA are essential. Treatment would likely include CPAP therapy for sleep apnea and bronchodilators for COPD. The combination of these conditions significantly increases his risk for cardiovascular complications and respiratory failure if left untreated 1.

From the Research

Physical Examination Findings

The patient's complaints of exhaustion, difficulty concentrating, loud snoring, and nocturnal thrashing, combined with a history of smoking two packs of cigarettes daily, suggest a high likelihood of obstructive sleep apnea (OSA) 2, 3.

• The most useful observation for identifying patients with OSA is nocturnal choking or gasping, with a summary likelihood ratio of 3.3 3.
• Snoring is common in OSA patients but is not useful for establishing the diagnosis, with a summary likelihood ratio of 1.1 3.
• Patients with a body mass index (BMI) lower than 26 and mild snoring are unlikely to have moderate or severe OSA, with a likelihood ratio of 0.07 3.
• A comprehensive sleep history and physical examination, including a detailed evaluation of the head and neck, are essential for guiding the decision to pursue diagnostic testing 4, 2.
• The patient's smoking history and lack of recent medical examination may also contribute to the presence of other respiratory system pathologies, highlighting the importance of a thorough respiratory system-focused patient history and physical examination 5.

Relevant Factors

• The patient's age, smoking history, and symptoms of exhaustion and difficulty concentrating may be related to the presence of OSA or other sleep disorders 4, 2.
• The patient's history of not being examined by a healthcare provider in over 20 years may contribute to the presence of undiagnosed conditions, including OSA or other respiratory system pathologies 5.
• The use of complete blood count parameters, such as mean platelet volume (MPV), platelet distribution width (PDW), and red cell distribution width (RDW), may be useful in assessing cardiovascular risk in patients with OSA 6.